NHS COMPLIANCE CODE OF CONDUCT

Transcription

1 NHS COMPLIANCE CODE OF CONDUCT

2 GOALS Understand Compliance Understand NHS s role & your role in Compliance Understand non-compliance Know who to contact when you have questions or concerns related to Compliance

3 DEFINITION OF COMPLIANCE Acting according to certain accepted standards. A system of rules and standards mandated by the government to prevent fraud and abuse.

4 OUR COMPLIANCE PROGRAM Is based on written policies and procedures that state our commitment to comply with all federal and state standards Includes a Compliance Officer and Compliance Committee which reports to the Board. Provides Compliance Education and Training Keeps open lines of communication including anonymous reporting. Requests investigation into allegations of noncompliance and enforcement of disciplinary actions as needed. Requests reviews of internal areas, especially areas of high risk Ensures that identified problems are remedied.

5 YOUR RESPONSIBILITIES As an employee you are a vital part of our efforts to prevent, detect and report noncompliance as well as possible fraud, waste and abuse. Your responsibilities include: Understanding and complying with laws and regulations. Knowing and following our Compliance Plan and Code of Conduct Looking out for suspicious activity Making sure that information provided to you is accurate and timely Reporting violations of our compliance policies and procedures to your supervisor or to the Compliance Committee or by using the anonymous hotline

6 NHS Responsibilities We will treat information reported by employees confidentially to the extent possible, and we will investigate. We will not allow retaliation against an employee who makes a good-faith report of a suspected violation. We will report violations to the appropriate outside agency if necessary.

7 Consequences for Non-Compliance NHS faces penalties for noncompliance with Medicare requirements. Sanctions vary with the severity of the problem and can be significant. Penalties may include: Medicare and Medicaid contract suspension or termination. Criminal convictions and fees Loss of provider license and/or exclusion from federal programs Imprisonment Employees who violate policies, procedures or laws face disciplinary action, up to and including termination of employment. Employees who know of violations but fail to report them are also subject to disciplinary action.

8 Conflicts of Interest Conflict of Interest issues: Receiving gifts or favors from a customer or supplier Participating in activities at or working for organizations that compete with NHS. A conflict of interest is a situation in which you have a personal interest that interferes with (or appears to interfere with) your ability to do your job. Our policy regarding conflicts of interest is simple: Don t compete with our organization Never let business dealings be influenced by personal or family interests

9 GIFTS AND KICKBACKS Gifts to hospital employees are generally intended as expressions of appreciation; but gifts of any kind may create an appearance of improper behavior. Do not solicit or demand anything for personal use or benefit from any vendor In very limited cases, it may be considered to be appropriate to accept a gift from a vendor. Such cases must be approved by the Compliance Officer, the General Counsel, the Chief Operating Officer or the Chief Executive Officer, or in the case of items with a total value of less than $100, by the Vice President responsible for your Department. However, meals or other gifts from pharmaceutical or medical device representatives are expressly prohibited by this policy. Report offers of gifts or kickbacks to your manager or to the Compliance Officer. A good rule of thumb is when in doubt, don t.

10 Competing with our Organization A conflict of interest arises when any personal interest interferes with your ability to do your job fairly and ethically. If you deal with contractors, suppliers and competitors, you must not take advantage of your position at NHS to obtain personal benefits for yourself or any family member or friend. Many factors are considered in determining whether a conflict of interest exists. Anything which may give the appearance of conflict of interest must be disclosed to your supervisor, including situations where family members or friends are involved. If you are unsure if a conflict exists, you should discuss the situation with your supervisor or the Compliance Officer to avoid possible misunderstandings and embarrassment.

11 Breach of Confidentiality Protected Health Information (PHI) cannot be shared with anyone other than authorized staff with a Need to Know. You must NEVER discuss confidential information or leave it where unauthorized people can hear or view it. Respect for the privacy of those we serve must be maintained at all times including public or common work areas. Breach of Confidentiality may result in termination of employment.

12 IMPROPER BILLING = FRAUD Everything we charge for and all orders must be properly documented. Medicare calls improper billing fraud even when it was not done intentionally. Medicare Fraud is a general term for any scheme to collect money from the Medicare system illegitimately. For example: Billing for services that were never done or were not documented Billing for services that are medically unnecessary Using an improper billing code to receive a higher payment rate Incorrect charges, units or amount of time spent.

13 Improper Documentation All coding and documentation must be accurate Registrations must have correct insurance information We cannot claim to have performed services or procedures that were not documented. We cannot claim that a patient s diagnosis is anything other than what was documented. Unauthorized destruction, removal and/or use of NHS documents is prohibited.

14 Improper Orders All orders must be legibly signed and dated. Signature stamps are not acceptable. All orders must be within the scope of practice of the ordering clinician. Employees cannot order their own tests or request curbside consults from other clinicians. Employees who have health concerns or questions should go to their own PCP, the Employee Health Department or the Emergency Room in an emergency.

15 Anti-Fraud Laws These are the laws used to combat Medicare fraud, waste and abuse: The False Claims Act The Anti-Kickback Statute The Physician Self-Referral Law HIPAA The Criminal Healthcare Fraud Statute

16 The False Claims Act protects the Government from being overcharged or sold substandard goods or services - for example being billed for services that were not provided. The Anti-Kickback Statute prohibits providers from paying physicians or clinicians for referrals of patients. Contracts with physicians must be carefully reviewed for appropriate terms conditions and signatures The Physician Self-Referral Law (or Stark Law) prohibits self-referral arrangements, in which a physician refers patients to entities with which the physician (or his/her family member) has a financial relationship HIPAA (The Health Insurance Portability and Accountability Act) is best known for protecting the privacy of personal health information and promoting standardization and efficiency in the healthcare industry. HIPPA established a fraud and abuse Control Program to coordinate federal, state and local enforcement activities The Criminal Healthcare Fraud Statute established health care fraud as a federal offense. It prohibits schemes that defraud any healthcare benefit program in connection with the delivery of or payment for healthcare benefits

17 Penalties for Fraud Violations of these laws can lead to severe penalties: A violation of the Anti-Kickback Statute can lead to imprisonment for up to 5 years and fines of up to $250,000 for an individual or $500,000 for a corporation. A violation of the False Claims Act can lead to criminal penalties of triple the amount of damages sustained by the government, as well as a civil penalty of $5,500 to $11,000 per false claim. A violation of the Stark Law can lead to civil penalties of up to $15,000 for each healthcare service that was performed as a result of an improper self-referral. An arrangement to circumvent the Stark Law can incur a civil penalty of up to $100,000. Federal law authorizes the imposition of civil monetary penalties for healthcarerelated misconduct.

18 Reporting All employees have a responsibility to understand and follow our organization s policies, procedures and laws. Seek out your supervisor for assistance in addressing concerns or contact a member of the Compliance Committee. To report anonymously, use one of the confidential hotlines

19 Reporting Compliance Violations Anonymous Compliance Hotline - (866) #1 - Behavioral Health #2 - Hospital, NMP & most areas of Senior Health - (800) Senior Health (Ledgewood & Seacoast) Anonymous Meditech Option (anonymous) - User ID - Password = Compliance - Recipient There are also outside options for reporting any issues or concerns. Refer to the Compliance Plan on NIC for more information

20 Improper Use of Social Networking Employee s conduct reflects on and impacts NHS even when off duty. Employees should exercise personal responsibility whenever involved in social networking. If the subject of the discussion is NHS, or those affiliated with NHS, employees must be mindful of the following guidelines: Do not disclose any information that would be considered confidential and/or protected by HIPAA Do not use discriminatory comments, personal insults, libel or slander when commenting about NHS superiors, co-workers or competitors! Confidentiality and HIPAA privacy rules still apply even if you are not on work time!

21 PUTTING IT TOGETHER! Compliance is everyone s responsibility. We re all liable under the law. Violations can be reported via our Confidential Meditech Hotline or . There will be no retaliation or adverse actions toward any employee who makes a good-faith report of a suspected violation.

22 REMEMBER!! IT TAKES LESS TIME TO DO THE RIGHT THING THAN IT DOES TO EXPLAIN WHY YOU DID IT WRONG!!! (Henry Wadsworth Longfellow)